Thursday, November 19, 2009

Retort to Change in Breast Cancer Prevention Protocols

This week, lurid headlines were in all United States papers proclaiming a government charged task force of "experts" recommended rolling back frequency of breast mammograms from annually to once a decade if you are age 40 or wait fifteen years if you are age 35. My first reaction was WTF, followed by; I wonder how much they paid for this study. Since I am twice a breast cancer survivor, I consider myself to be somewhat of an "expert" and I have a health policy background. According to the Center for Disease Control, 74.6% of women in the United States who were forty and older received mammograms in 2005. The latest recommendation published in the Annals of Internal Medicine could have an adverse impact on the mammography rate for American women. In order to be fair, let us examine this from a rational perspective.The most salacious reason cited for reducing the prevalence of mammography in pre-menopausal women was the potential harm of the screening process. Excuse me, you mean the harm of having to obtain a second mammogram because of careful screening and a potential false positive result? This is a good thing as the level of scrutiny for abnormal breast tissue is high in order to save lives. If these folks are concerned about the radiation exposure, the exposure from the sun is worse and certainly contributes to more incidence of cancer than prophylactic breast radiation. Or perhaps it was the horror of the stereo tactic needle biopsy, about as challenging as a blood draw. What exactly are the harmful effects this panel of experts was talking about, a poke in your boob? Or are women really so shallow that a mark or scar on their breast is more important than surveillance for a potentially fatal disease.In 1993, when I had my first BC diagnosis, I was told that 6,500 women who were under age forty in the United States died from the disease each year, and that I was an anomaly. I was also given literature on how slow growing the disease was and that it primarily impacted grandmothers. Since I was 35 at the time, I decided to do my own research, finding European data on treatment for pre-menopausal women. I knew several women who had died of this disease at the time and the only thing we had in common was an education and a career, which typically meant late or not-at-all child bearing. In my case there was no family history of breast cancer that was disproportionate with the general population.The proviso this panel of experts make that high-risk women should obtain mammograms excludes one consideration, we don’t typically know who these people are, unless they have been to an oncologist, which would include mammography. The difficulty in preventing cancer mortality is due in part to the elusiveness of the disease indicators and the optimal way to prevent deaths is to have broad population cancer surveillance. Breast cancer mortality is affected by patterns of early detection and quality of care. According to a recent report in the Cancer Journal for Clinicians, which reviewed breast cancer data from 1996 to 2006, breast cancer mortality is declining in the United States. The article also reviewed global breast cancer data and noted the mortality reduction in breast cancer cases was indicative of the early screening, detection, and therapeutic treatments. Why would the United States want to reduce the gains made in saving lives with this virulent form of cancer?In 2003, ten years after my initial diagnosis, my oncologist informed me, that I had the same type of cancer in my other breast. At that time I was 46 and based on the recommendations from the aforementioned expert panel, I would have come under the high-risk category and have been able to obtain a mammogram with regularity. Of course I would have died at age 36 without my initial mammogram, since baseline mammograms for women under age 50 are not a recommendation from the panel. At the time of my second diagnosis, I was a graduate student in a top ten public university and a widow with a seven-year-old child. Mammography, which I had annually, was the thing that saved me both times. Was my life not worth saving, according to this panel it was just an anomaly.Second finding, breast self-exams are not beneficial in diagnosing early stages of breast cancer. Duh, someone finally figured this out. First of all if there is a lump in your breast and you can feel it, that is a big tumor. Mine was two centimeters and I couldn’t feel it at all. Secondarily, many lumps are benign or noncancerous. Finding a lump is not an effective early detection method for cancer.Thirdly, the inference that the emotional trauma from a potentially false positive mammogram is too overwhelming for females smacks of condescension. Aren’t women responsible for their own health? Why not let women make decisions after they have all of the facts. Note to self, the American Cancer Society does NOT agree with these new recommendations to curtail mammography for women that are under age fifty. For those females who feel that having their boob squeezed is not worth potential cancer prevention, that may not be the most well informed choice, but it their option.Fourth finding, that mammograms for younger women aren’t reliable because of the difficulty in scanning dense breast tissue. What a bunch of huey! I had less than 17% body fat during my initial diagnosis, which found the presence of abnormal tissue in my first mammogram. Mammograms can be performed for women with all breast densities, especially by the better centers. It is helpful to have your "boob shot" taken at the same center so they become familiar with your tissue anomalies. Also, for those professionals who feel they are challenged with imaging more youthful breast tissue, become competent at your job.Finally, I am concerned about the implications for insurance reimbursement, which may choose to limit coverage for breast cancer diagnostic procedures for women under age fifty. Hopefully some university professor is currently assigning a cost benefit analysis project about mammograms for women under age fifty. In conclusion, for women who may not feel they can cough up the money for a mammogram, I ask you, what is your life worth? Also, there are nonprofit organizations like the www.cancerlifeline.org that have funds to pay for these services. If in doubt, get a second opinion, and keep asking questions until you feel informed about your own health.